HomeMy Public PortalAbout8733 HERMOSA DR_Sewer__ C E8A08 0-63
76642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDREss
WILLIAM A. JENSEN, Supt of Building V
LOCALTY
NEAREST
FOR�APP NT TO LIN CROSS ST
LE _
DESCRifh O OT NO. OWNER
(/ MAIL
BLOCK ( TRACT `( 90oBL�5 ADDRESS
SIZE OF LOT Y HOW ON LOT CITY T.L. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCE$$E BY
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CONTRACTOR
CCC )
ADDRESS 3 Z S CONNECTION DATA
CITY S TELSTATION I DEPTH
�f .2 ❑ TATE MANHOLE REFERENCE - UPPER
REGISTRATION NO, wLO �p( ❑ SCOUNTY
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOU.E SEWER CONNECTING TO Y, Cu 8 i M.L TO P,L Y
PUBLIC SEWER @ 35,00 1 `j
SEPTIC TANK.SEEPAGE PIT OR D��, �/ JOB NO. L � O
PITS NC/O.GRAINFIELD @ 510.00 V
HO u
PRIVATE DISPOSAL SYSTEM 33.00
TO Q 33.00 SE SEWER TRUNK PERMIT NO. ROAD PERMIT NO. l�
CONNECT ADDITIO NAL BLDG.OR AFFIVIT eIv ps[n[
DARECORD.INSTR.NO. DATE F
WORK TO HOUSE SEWER @ 33.00 �� u
OVERFLOW SEEPAGE PIT.ORAINFI ETO W
a
AFTER REPAIR L.DRYW ELL.MANHOLE 85.00 HWY.OR ST,WIDENING �
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® 43.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00
CONNECTION CHARGE FEE CHARGES
ALTTHORIZATION I TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S 5IGNATURE
SIGNED THIS DA O 1g_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK PITIS)'
AND/0
DRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAW. REGULATING
PW MBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
CE
LINSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DI.CONNECT PLUG AND
RESIOE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATIO --"p ROBERT A. WOOD
CK. M.0. Cq.N
SUPERVISING MECHANICAL ENGINEER
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